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2/17/2015
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Karen Vance, OTRManaging ConsultantBKD, LLP
Tuesday, February 17, 2015 | 2 – 3 p.m. Central time
2015 Home Health Medicare Payment & Regulatory Updates – Part 2
To Receive CPE Credit
• Participate in entire webinar• Answer polls when they are provided• If you are viewing this webinar in a group
o Complete group attendance form with Title & date of live webinar Your company name Your printed name, signature & email address
o All group attendance sheets must be submitted to [email protected] 24 hours of live webinar
o Answer polls when they are provided• If all eligibility requirements are met, each participant will be
emailed their CPE certificates within 15 business days of live webinar
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Objectives
• Articulate rationale for therapy reassessments • Define 2015 regulatory changes for therapy reassessment
timing• Describe changes needed in home health agency
operations for monitoring reassessments• Elucidate potential changes beyond 2015 & impact on
therapy utilization• Explain changes in therapy practice needed for home
health success
3 // experience access
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RATIONALE FOR REASSESSMENTRationale for Reassessments
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Rationale for Therapy Reassessment Requirement
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Rationale for Therapy Reassessment Requirement
• “Effective January 1, 2011, therapy reassessments must be performed on or ``close to'' the 13th and 19th therapy visits and at least once every 30 days (75 FR 70372). A qualified therapist, … must functionally reassess the patient using a method which would include objective measurement.”
• “We anticipated that policy regarding therapy coverage and therapy reassessments would address payment vulnerabilities that have led to high use and sometimes overuse of therapy services. We also discussed our expectation that this policy change would ensure more qualified therapist involvement for beneficiaries receiving high amounts of therapy.” (CMS-1611-F)
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Episode % – 14 & 20 Therapy Visits Table 35
Calendar year
Episodes with at least 1covered
therapy visit
Episodes with at least 14
covered therapy visits
Episodes with at least 20
covered therapy visits
2010 54.1 17.2 6.0
2011 54.2 16.0 5.4
2012 55.2 15.6 5.2
2013 56.3 16.3 5.3
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Visit % Provided by Therapy Assistants Table 36
Calendar year % PT visits provided by a PTA
% OT visits provided by an OTA
2011 23.8 14.4
2012 28.5 15.4
2013 29.2 15.4
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RATIONALE FOR REASSESSMENT2015 Rule
Federal Register Volume 79, Number 215 (November 6, 2014)
• “We note that in our CY 2012 HH PPS final rule (76 FR 68526), we recalibrated and reduced the HH PPS case-mix weights for episodes reaching 14 and 20 therapy visits, thereby diminishing the payment incentive for episodes at those therapy thresholds.
• Recent analysis of claims data from CY 2010 through CY 2013 does not show significant change in the percentage of cases reaching the 14 therapy visit and 20 therapy visit thresholds between CY 2010 and CY 2011.
• Moreover, payment increases at the 14 therapy visit and 20 therapy visit thresholds have been somewhat mitigated since the recalibration of the case-mix weights in CY 2012.”
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Federal Register Volume 79, Number 215 (November 6, 2014)
• Effective for episodes beginning on or after January 1, 2015• At least every 30 days a qualified therapist (instead of an
assistant) must provide the needed therapy service and functionally reassess the patient.
• Where more than one discipline of therapy is being provided, a qualified therapist from each of the disciplines must provide the needed therapy service and functionally reassess the patient at least every 30 days.
(Emphasis added)
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RATIONALE FOR REASSESSMENTMonitoring Reassessments
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Monitoring Reassessment Visits
• “The reassessment will not have to be done on exactly the 30th day. For example, the reassessment could be done on the 21st day or the 28th day as clinically appropriate and deemed necessary by the therapist.”
• Reassessment clock is not measured by episode but by patient's full course of treatment, starting with therapist's first assessment/visit & continuing until patient is discharged from home health
• Each therapy discipline has its own separate clock, beginning with first therapy service (of that discipline) & clock resets with each therapist's visit/assessment/measurement/ documentation (of that discipline)
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Federal Register Volume 79, Number 215 (November 6, 2014)
• Therapy reassessments are to be performed o Using a method that would include objective
measurement o In accordance with accepted professional standards of
clinical practiceo Which enables comparison of successive measurements
to determine effectiveness of therapy goals
• Unchanged from original 2011 Rule
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Therapy Reassessment Documentation
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• Does not require a full blown evaluation to the extent of initial evaluation
• Does require an ‘intervention review’, demonstrating effectiveness of intervention
• Does not have to be on a particular form
• Does have to be recognizable as a reassessment
• Clarification added to documentation later must be a “legal late entry”
Therapy Reassessment Elements
• Functionalo Goals & interventions must satisfy, “so what?” assuring
appropriateness to patient
• Objective o Terms or measures used to mean same thing, by any
therapist, any time they are used
• Measurableo Progress measured is countable
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Objective Measures
• OASIS functional items or other commercially available therapy outcomes instruments OR
• Tests & measurements validated in professional literature OR
• Accepted standards of clinical practice appropriate for condition/function being measured
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Standards of Clinical Practice
• Include guidelines or frameworks that guide clinical reasoning through assessment, goal setting, plans of care & discharge planning
• Include ethical standards• Include guidelines for supervision• Require practice within regulatory & payment policy
of employment setting• Assure practice & measures are appropriate for
home health
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Objective vs. Standardized Measures
• If a tool is standardized but not for home health, it is not appropriate to be used as a standardized tool
• If a standardized tool is adapted to fit home health, then it is no longer standardized
• There may be accepted standards of clinical practice that may be appropriate for home health, but notobjective & not measurable
• Define measures you are currently using to make them objective & measurable
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Therapy Reassessment = Intervention Review
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• Re-evaluate plan
• Modify plan
• Justify continuing or discontinuing plan
• Re-evaluate plan, not patient
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Clinical Reasoning OVER Rules
• Be careful to not be so concerned about measuring progress that is standardized or measurable that you find yourself documenting progress not salient to patient’s goals
• Be careful about following “rules of thumb” & prescribed documentation that you don’t catch what is important about patient’s performance
• Consider variables of performance that can be measured incrementally
• Level of assistance & increments of strength or ROM do not always describe a patient’s function
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Documentation Standards
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“The service of a physical therapist, speech-language pathologist or occupational therapist is a skilled therapy service if inherent complexity of the service is such that it can be performed safely and/or effectively only by or under the general supervision of a skilled therapist. To be covered, the skilled services must also be reasonable and necessary to the treatment of a patient's illness or injury or to the restoration or maintenance of function affected by the patient's illness or injury.“ (Emphasis added)
Benefit Policy Manual, 40.2.1
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RATIONALE FOR REASSESSMENTBeyond 2015
Volume- to Value-Based Health Care
• Quality data, from patient’s perspective, is often not meaningful & is incomplete, with little information available to compare expected functional outcomes among providers
• But main culprit for current system’s ills is fee-for-service payment system, which rewards volume over value & does nothing to promote coordination of care among providers
• First step in correcting system is a transition from volume-based to value-based methods of payment
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Healthcare Financial Management Association (HFMA). (2011). Value in health care: current state and future directions. Retrieved from www.hfma.org
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Medicare Payment Advisory Commission (MedPac)
“The Secretary should revise the home health case-mix system to rely on patient characteristics to set payment for therapy and nontherapy services and should no longer use the number of therapy visits as a payment factor.”
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Value-Based Health Care
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Healthcare Financial Management Association (HFMA). (2011). Value in health care: current state and future directions. Retrieved from www.hfma.org
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Volume-Based Practices
• 13th & 19th therapy reassessments• Documentation justifying visits to payor• Documenting progress & need• Using same visit frequency & duration• Defending volume of services to justify associated
payment
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Value-Based Practices
• Selecting services based on contribution that service will make toward desirable & sustainable outcomes
• Justification, not to the payor, but to the agency, that services are worth providing
• Value-based practices require different skills & knowledge (competencies) than volume-based practices
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RATIONALE FOR REASSESSMENTTherapy Skill Set
Most Common Primary Home Health Diagnosis, Medicare Beneficiaries (2010)
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Diagnosis ICD-9-CM Code% total served with this HH 1o diagnosis
Diabetes 250 10.3
Essential hypertension 401 9.3
Heart failure 428 7.4
Chronic ulcer of skin 707 4.3
Osteoarthrosis related dx 715 3.7
Cardiac dysrhythmias 427 2.6
Total 37.6Source: From Medicare and Medicaid Statistical Supplement, 2010 Edition, Centers for Medicare & Medicaid Services, 2011
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Management of Chronic Conditions
• “As much as 90% of the management of a chronic condition must be performed, not by health care providers, but by the person who has the condition.”
California Healthcare Foundation, 2008
• “Patients with chronic conditions self-manage their illness. This fact is inescapable. Each day, patients decide what they are going to eat, whether they will exercise, and to what extent they will consume prescribed medication.”
Bodenhemer, Lorig, Holman & Grumbach, 2002
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Don’t Confuse . . .
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Knowledge Behavior
Verbalize Understanding Implementation
Return Demonstration Spontaneous Performance
One Time Routine
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Outcomes
• What will result of therapy intervention be?• Will it be sustainable?
o Capable of being sustainedo Resources needed to sustain
• Will it matter?• A shift in metrics from possible to practical
o Are resources required to achieve result worth the resultachieved?
o Are resources required to sustain result reasonable?
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Management of Chronic Conditions
• Medications (obtain, administer as directed, refill)• Self monitoring (BP, glucose, skin)• Other treatments (oxygen, nebulizer, insulin)• Physical activity (exercise, pacing)• Diet (carbs/glycemic index, sodium, potassium)• Attend & participate in health care encounters
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Outcome Indicators
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Outcomes Measures State Nat’l
How often patients got better at walking or moving around. 63% 63%
How often patients got better at getting in and out of bed. 61% 58%
How often patients got better at bathing. 72% 68%
How often patients had less pain when moving around 66% 68%
How often patients breathing improved. 70% 65%
How often patients’ wounds improved or healed after an operation. 90% 89%
How often patients got better at taking their drugs correctly by mouth. 53% 52%
How often patients receiving home health care needed any urgent, unplanned care in the hospital emergency room – without being admitted to the hospital 14% 12%
How often home health patients had to be admitted to the hospital 14% 16%
Satisfying All Stakeholders
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• Effectiveo Good
outcomes
• Productiveo Cost efficient
• Complianto Good
documenting
• Effectiveo Reduce
hospitalization
• Efficiento Reduced costs
• Complianto With
regulations
Agency Payor/Regulators Patient/ Support System
• Effectiveo Feel bettero Manage
conditiono Stay at home
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Continuing Professional Education (CPE) Credits
BKD, LLP is registered with the National Association of State Boards of Accountancy (NASBA) as a sponsor of continuing professional education on the National Registry of CPE Sponsors. State boards of accountancy have final authority on the acceptance of individual courses for CPE credit. Complaints regarding registered sponsors may be submitted to the National Registry of CPE Sponsors through its website: www.learningmarket.org.
The information in BKD webinars is presented by BKD professionals, but applying specific information to your situation requires careful consideration of facts & circumstances. Consult your BKD advisor before acting on any
matters covered in these webinars.
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CPE Credit
• CPE credit may be awarded upon verification of participant attendance
• For questions, concerns or comments regarding CPE credit, please email the BKD Learning & Development Department at [email protected]
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